Examining implicit bias of physicians who care for individuals with spinal cord injury: A pilot study and future directions

Identifying Racial and Ethnic Disparities in Acute Inpatient Rehabilitation

OBJECTIVE

To investigate whether racial, ethnic, and linguistic disparities exist at discharge from an acute inpatient rehabilitation facility (IRF) by examining change in Functional Independence Measure (FIM) scores and discharge destination.

DESIGN

This is a retrospective study using our IRF's data from the Uniform Data System for Medical Rehabilitation from 2013-2019. FIM scores and discharge destination were compared between race, language, and ethnic groups, with adjustment for patient characteristics.

SETTING

An urban hospital with a level 1 trauma center, comprehensive stroke center, and IRF with Commission on Accreditation of Rehabilitation Facilities (CARF) certification.

PARTICIPANTS

2518 patients admitted to the IRF from 2013-2019 (N=2518).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Change in FIM score and discharge destination.

RESULTS

After adjusting for covariates, non-White patients and patients with limited English proficiency had significantly lower functional recovery, as measured by smaller changes in FIM scores from IRF admission to discharge. Additionally, both groups were more likely to be discharged home with home health care than to a skilled nursing facility, compared with White and English-speaking patients. Disparities in discharge destination persisted within patients with noncommercial insurance (Medicaid or Medicare) and a stroke diagnosis but not within those who had commercial insurance or a nonstroke diagnosis.

CONCLUSIONS

Racial and linguistic disparities were identified within our CARF certified IRF; however, the organization is committed to reducing health care disparities. Next steps will include investigating interventions to reduce disparities.

Perceived stress and pain interference in acute rehabilitation following spinal cord injury: Resilience as a moderator

PURPOSE/OBJECTIVE

Higher levels of resilience is associated with improved pain outcomes in chronic pain and other neurological populations, but the role of resilience in pain following spinal cord injury (SCI) remains unclear. This study examined resilience as a moderator in the relationship between perceived stress and both pain intensity and interference during acute rehabilitation for SCI.

RESEARCH METHOD/DESIGN

Individuals admitted to inpatient rehabilitation acutely following SCI (N = 57) completed measures of perceived stress, resilience, pain intensity, and interference. The Johnson-Neyman procedure was used to examine significance of conditional relationships that emerged.

RESULTS

Resilience was found to moderate the relationship between perceived stress and pain interference, but not pain intensity, during inpatient rehabilitation.

CONCLUSIONS/IMPLICATIONS

When resilience is low, perceived stress has a more profound and adverse impact on pain interference during inpatient rehabilitation, suggesting therapeutic strategies that build components of resilience are needed during acute rehabilitation following SCI. The relationship between stress, resilience, and pain may differ postinpatient rehabilitation for SCI and warrants further investigation. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

A Systematic Review of the Effects of Provider Bias on Health in Youth and Young Adults with Type 1 Diabetes

PURPOSE OF REVIEW

Although pervasive inequities in the health outcomes of youth and young adults with type 1 diabetes (T1D) exist, the role of provider bias in these inequities is not well-understood. The purpose of this review is to synthesize evidence from existing studies on the associations between patient characteristics, provider bias, and patient health.

RECENT FINDINGS

Fourteen articles were included. Determining the extent of the effects of provider bias on patient health is limited by a lack of consensus on its definition. Experiences of provider bias (e.g., shaming, criticism) negatively affects self-esteem, relationships with medical providers, and depressive symptoms. Provider bias also impacts diabetes technology recommendations, insulin regimen intensity, and risk for life-threatening T1D complications. Future studies are needed to develop questionnaires and interviews that better account for diverse experiences and interpretations of bias in T1D healthcare. More research is also needed to investigate mitigating factors to reduce provider bias as a way to improve psychological and physical health in individuals with T1D.

Sexual Orientation and Racial Bias in Relation to Medical Specialty

Physician explicit and implicit biases involving race and sexual orientation (SO) affect patient and provider experiences in healthcare settings. An anonymous survey was disseminated nationally to graduating medical students, residents, and practicing physicians to evaluate SO and racial biases across medical specialties. SO explicit and implicit bias were measured with the Attitudes toward Lesbians and Gay Men Scale, short form (ATLG-S) and Gay-Straight Implicit Association Test (IAT). Racial explicit and implicit bias were measured with the Quick Discrimination Index (QDI) and the Black-White IAT. Medical specialty was associated with racial explicit bias and specialty prestige with Black-White IAT score. Medical specialty and specialty prestige were not associated with SO bias. Female sex, sexual and gender minority (SGM) identity, and decreased religiosity were associated with reduced SO and racial bias. Provider race was associated with racial implicit and explicit bias.

Potential influence of nurses' implicit racial bias on maternal mortality

Stark disparities persist in maternal mortality and perinatal outcomes for Black and other birthing people of color, such as Native Americans, and their newborns compared to White people in the United States. An increasing body of research describes the phenomenon of implicit racial bias among providers and how it may affect communication, treatment decisions, the patient care experience, and health outcomes. This synthesis of literature reviews and distills current research on the presence and influence of implicit racial bias among nurses as it may relate to maternal and pregnancy-related care and outcomes. In this paper, we also summarize what is known about implicit racial bias among other types of healthcare providers and interventions that can mitigate its effects, identify a gap in research, and recommend next steps for nurses and nurse researchers.

Racial Disparities in Pediatric Inflammatory Bowel Disease Care: Differences in Outcomes and Health Service Utilization Between Black and White Children

OBJECTIVE

To describe racial inequities in pediatric inflammatory bowel disease care and explore potential drivers.

METHODS

We undertook a single-center, comparative cohort study of newly diagnosed Black and non-Hispanic White patients with inflammatory bowel disease, aged <21 years, from January 2013 through 2020. Primary outcome was corticosteroid-free remission (CSFR) at 1 year. Other longitudinal outcomes included sustained CSFR, time to anti-tumor necrosis factor therapy, and evaluation of health service utilization.

RESULTS

Among 519 children (89% White, 11% Black), 73% presented with Crohn's disease and 27% with ulcerative colitis. Disease phenotype did not differ by race. More patients from Black families had public insurance (58% vs 30%, P < .001). Black patients were less likely to achieve CSFR 1-year post diagnosis (OR: 0.52, 95% CI:0.3-0.9) and less likely to achieve sustained CSFR (OR: 0.48, 95% CI: 0.25-0.92). When adjusted by insurance type, differences by race to 1-year CSFR were no longer significant (aOR: 0.58; 95% CI: 0.33, 1.04; P = .07). Black patients were more likely to transition from remission to a worsened state, and less likely to transition to remission. We found no differences in biologic therapy utilization or surgical outcomes by race. Black patients had fewer gastroenterology clinic visits and 2-fold increased odds for emergency department visits.

CONCLUSIONS

We observed no differences by race in phenotypic presentation and medication usage. Black patients had half the odds of achieving clinical remission, but a degree of this was mediated by insurance status. Understanding the cause of such differences will require further exploration of social determinants of health.

Unconscious Bias among Health Professionals: A Scoping Review

BACKGROUND

Unconscious biases are one of the causes of health disparities. Health professionals have prejudices against patients due to their race, gender, or other factors without their conscious knowledge. This review aimed to provide an overview of research on unconscious bias among health professionals and to investigate the biases that exist in different regions of the world, the health professions that are considered, and the research gaps that still exist.

METHODS

We conducted a scoping review by systematically searching PubMed/MEDLINE, CINAHL, PsycINFO, PsycARTICLES, and AMED. All records were double-screened and included if they were published between 2011 and 2021.

RESULTS

A total of 5186 records were found. After removing duplicates (n = 300), screening titles and abstracts (n = 4210), and full-text screening (n = 695), 87 articles from 81 studies remained. Studies originated from North America (n = 60), Europe (n = 13), and the rest of the world (n = 6), and two studies were of global scope. Racial bias was investigated most frequently (n = 46), followed by gender bias (n = 11), weight bias (n = 10), socio-economic status bias (n = 9), and mental illness bias (n = 7). Most of the studies were conducted by physicians (n = 51) and nurses (n = 20). Other health care professionals were rarely included in these studies.

CONCLUSIONS

Most studies show that health professionals have an implicit bias. Racial biases among physicians and nurses in the USA are well confirmed. Research is missing on other biases from other regions and other health professions.

Implicit bias instruction across disciplines related to the social determinants of health: a scoping review

One criticism of published curricula addressing implicit bias is that few achieve skill development in implicit bias recognition and management (IBRM). To inform the development of skills-based curricula addressing IBRM, we conducted a scoping review of the literature inquiring, "What interventions exist focused on IBRM in professions related to social determinants of health: education, law, social work, and the health professions inclusive of nursing, allied health professions, and medicine?"Authors searched eight databases for articles published from 2000 to 2020. Included studies: (1) described interventions related to implicit bias; and (2) addressed knowledge, attitude and/or skills as outcomes. Excluded were interventions solely focused on reducing/neutralizing implicit bias. Article review for inclusion and data charting occurred independently and in duplicate. Investigators compared characteristics across studies; data charting focused on educational and assessment strategies. Fifty-one full-text articles for data charting and synthesis, with more than 6568 learners, were selected. Educational strategies included provocative/engagement triggers, the Implicit Association Test, reflection and discussion, and various active learning strategies. Most assessments were self-report, with fewer objective measures. Eighteen funded studies utilized federal, foundation, institutional, and private sources. This review adds to the literature by providing tangible examples of curricula to complement existing frameworks, and identifying opportunities for further research in innovative skills-based instruction, learner assessment, and development and validation of outcome metrics. Continued research addressing IBRM would enable learners to develop and practice skills to recognize and manage their implicit biases during clinical encounters, thereby advancing the goal of improved, equitable patient outcomes.

Racism in healthcare: a scoping review

BACKGROUND

Racism constitutes a barrier towards achieving equitable healthcare as documented in research showing unequal processes of delivering, accessing, and receiving healthcare across countries and healthcare indicators. This review summarizes studies examining how racism is discussed and produced in the process of delivering, accessing and receiving healthcare across various national contexts.

METHOD

The PRISMA guidelines for scoping reviews were followed and databases were searched for peer reviewed empirical articles in English across national contexts. No starting date limitation was applied for this review. The end date was December 1, 2020. The review scoped 213 articles. The results were summarized, coded and thematically categorized in regards to the aim.

RESULTS

The review yielded the following categories: healthcare users' experiences of racism in healthcare; healthcare staff's experiences of racism; healthcare staff's racial attitudes and beliefs; effects of racism in healthcare on various treatment choices; healthcare staff's reflections on racism in healthcare and; antiracist training in healthcare. Racialized minorities experience inadequate healthcare and being dismissed in healthcare interactions. Experiences of racism are associated with lack of trust and delay in seeking healthcare. Racialized minority healthcare staff experience racism in their workplace from healthcare users and colleagues and lack of organizational support in managing racism. Research on healthcare staff's racial attitudes and beliefs demonstrate a range of negative stereotypes regarding racialized minority healthcare users who are viewed as difficult. Research on implicit racial bias illustrates that healthcare staff exhibit racial bias in favor of majority group. Healthcare staff's racial bias may influence medical decisions negatively. Studies examining healthcare staff's reflections on racism and antiracist training show that healthcare staff tend to construct healthcare as impartial and that healthcare staff do not readily discuss racism in their workplace.

CONCLUSIONS

The USA dominates the research. It is imperative that research covers other geo-political contexts. Research on racism in healthcare is mainly descriptive, atheoretical, uses racial categories uncritically and tends to ignore racialization processes making it difficult to conceptualize racism. Sociological research on racism could inform research on racism as it theoretically explains racism's structural embeddedness, which could aid in tackling racism to provide good quality care.

Implicit biases and differential perinatal care for migrant women: methodological framework and study protocol of the BiP study part 3

BACKGROUND

The mechanisms of disparities in maternal and perinatal health between migrant and native women are multiple and remain poorly understood. Access to and quality of care are likely to participate in these mechanisms, and one hypothesis is the existence of implicit biases among caregivers through which ethno-racial belonging can influence medical decisions and consequently engender healthcare disparities. Their existence and their role in the generation of non-medically justified differential care have been documented in the United States apart from perinatal care, but remain largely unexplored in Europe. In this article, we present the study protocol and theoretical framework of a study that aims to test and quantify the existence of implicit bias toward African Sub-Saharan migrant women among caregivers working in the perinatal field, and to explore the association between implicit bias and differential care.

MATERIAL AND METHODS

This study is based on an online survey to which French obstetricians, midwives, and anesthetists were invited to take part. The potential existence of implicit biases toward African Sub-Saharan migrant will be quantified through a validated tool, the Implicit Association Test. Then we will assess how implicit biases are likely to influence clinical decisions and lead to differential care using clinical vignettes designed by an experts group.

DISCUSSION

Implicit bias and differential care are concept that are tricky to capture and interpret. This research program opens up in France a field of research on certain forms of health discriminations and sheds new light on the issue of social inequalities in perinatal health.

STUDY REGISTRATION

Registration in the Open Science Framework portal: https://osf.io/djva7/?view_only=c6012ace3fe94165a65b05c2dc6aff9e.

Health Care Disparities Add Insult to Spinal Cord Injury

The authors describe the disparities and increased risk of traumatic spinal cord injury Black Americans face because of violence. This article should serve as a realization of these inequities and as a call to action to improve the equity of rehabilitation services in this population to improve outcomes.

Predicting Duration of Outpatient Physical Therapy Episodes for Individuals with Spinal Cord Injury Based on Locomotor Training Strategy

OBJECTIVE

To characterize individuals with spinal cord injuries (SCI) who use outpatient physical therapy or community wellness services for locomotor training and predict the duration of services, controlling for demographic, injury, quality of life, and service and financial characteristics. We explore how the duration of services is related to locomotor strategy.

DESIGN

Observational study of participants at 4 SCI Model Systems centers with survival. Weibull regression model to predict the duration of services.

SETTING

Rehabilitation and community wellness facilities at 4 SCI Model Systems centers.

PARTICIPANTS

Eligibility criteria were SCI or dysfunction resulting in motor impairment and the use of physical therapy or community wellness programs for locomotor/gait training. We excluded those who did not complete training or who experienced a disruption in training greater than 45 days. Our sample included 62 participants in conventional therapy and 37 participants in robotic exoskeleton training.

INTERVENTIONS

Outpatient physical therapy or community wellness services for locomotor/gait training.

MAIN OUTCOME MEASURES

SCI characteristics (level and completeness of injury) and the duration of services from medical records. Self-reported perceptions of SCI consequences using the SCI-Functional Index for basic mobility and SCI-Quality of Life measurement system for bowel difficulties, bladder difficulties, and pain interference.

RESULTS

After controlling for predictors, the duration of services for the conventional therapy group was an average of 63% longer than for the robotic exoskeleton group, however each visit was 50% shorter in total time. Men had an 11% longer duration of services than women had. Participants with complete injuries had a duration of services that was approximately 1.72 times longer than participants with incomplete injuries. Perceived improvement was larger in the conventional group.

CONCLUSIONS

Locomotor/gait training strategies are distinctive for individuals with SCI using a robotic exoskeleton in a community wellness facility as episodes are shorter but individual sessions are longer. Participants' preferences and the ability to pay for ongoing services may be critical factors associated with the duration of outpatient services.

Implicit racial bias among medical graduates and students by an IAT measure: a systematic review and meta-analysis

INTRODUCTION

Racial implicit bias is an unconscious response and behavior that affects interpersonal interactions and clinical decision-making.

AIMS

We attempted to meta-analyze the scores of implicit association test (IAT) to estimate pooled quantity of implicit racial bias among medical graduates and students METHODS: As far as we know, our study is the first systematic-based meta-analysis estimating the pooled score of implicit racial bias among physicians and medical students. Keywords were searched in Scopus, Web of Science, Google Scholar, PubMed, Science Direct, Cochrane, MEDLINE, Wiley online library, and ProQuest databases from 2011 since 2021. The IAT's pooled score estimates through a fixed-effect meta-analysis using STATA 15. Also, I² statistic was used to determine heterogeneity across the articles.

RESULTS

Out of 1177 articles, 29 studies entered to analysis. The pooled score of IAT among physicians and medical students was 0.28 (95% CI 0.13 to 0.43) and 0.35 (95% CI 0.03 to 0.67), respectively. The racial bias score of physician ranged from -0.12 to 0.62. While score of implicit association test for medical student ranged from -0.01 to 1.29.

CONCLUSION

Our meta-analysis revealed that there was an implicit anti-black attitude among physicians and medical students, but the size of this implicit racial bias was small. Although the level of racial bias in physicians and medical students was low, it could be reduced to the lowest level through informative programs and training in ways to control implicit attitudes.

Does women's place of birth affect their opportunity for an informed choice about Down syndrome screening? A population-based study in France

Background

To examine disparities by maternal place of birth in the opportunity to make an informed choice about Down syndrome screening, in France, where the national guidelines recommend that physicians offer it to all pregnant women.

Methods

We used population-based data from the nationally representative French Perinatal Surveys in 2010 and 2016 (N=24,644 women) to analyze the opportunity for an informed choice for prenatal screening, measured by a composite indicator.

Results

Among the 24 644 women in the study, 20 612 (83.6%) were born in France, 861 (3.5%) elsewhere in Europe, 1550 (6.3%) in North Africa, and 960 (3.9%) in sub-Saharan Africa. The probability of screening was lower for women born outside France. After adjustment for survey year, maternal age, parity, education level, and the maternity unit’s level of perinatal care, women born outside France had the opportunity to make an informed choice less often than women born in France. This association remained essentially the same even after excluding women without adequate prenatal care.

Conclusions

Women born outside France, including those with adequate prenatal care, had less opportunity than women born in France to make an informed choice about prenatal screening for Down syndrome.

An Examination of History for Promoting Diversity in Neuroscience

Purpose of Review

A review of American history is presented to understand how public policy has contributed to a disproportionate burden of disease in members of underrepresented groups. A review of research conducted in the Stroke Belt provides an opportunity to examine more closely traditional and non-traditional risk factors in an effort to consider strategies for change.

Recent Findings

A diverse physician workforce has been offered as a way of improving care for our increasingly diverse populace. Given the expected increased prevalence of stroke in communities of color and the impact of stress from discrimination on health, proactive strategies to promote inclusion and equity to support diversity in perioperative neuroscience is warranted.

Summary

Public policy rooted in structural racism has left marginalized groups economically and educationally disadvantaged with less access to health care. Mistrust and fear from ongoing discrimination compels the neuroscience community to broaden their approach for developing a more reassuring and supportive educational environment for patients and trainees.

Influence of Socioeconomic Bias on Emergency Medicine Resident Decision Making and Patient Care

INTRODUCTION

Physician bias impacts clinical decision making, resulting in disparities in patient care. Most existing studies focus on sex and racial bias. This study aimed to investigate disparities in physician decision making among patients of varying socioeconomic status (SES).

METHODS

Emergency medicine residents (n = 31) participated in 3 consecutive scenarios of similar disease acuity but with standardized patients of varying SES. Following the scenarios, residents met with a standardized participant acting as an attending physician for a handoff to recount their decision-making processes and care recommendations. Blinded raters evaluated clinical performance using an objective assessment tool. We assessed associations between patient SES and resident-ordered imaging, ordered medication, patient-perceived empathy, and clinical performance. We used qualitative analyses to study residents' decision-making processes.

RESULTS

Quantitative analyses revealed no significant relationship between SES and resident-ordered imaging, ordered medications, patient-perceived empathy, and clinical performance. Qualitative analyses revealed 3 themes regarding clinical decision making: (1) overt diagnostic focus, (2) discharge planning, and (3) risk and exposure.

CONCLUSIONS

Although quantitative analyses showed that SES did not affect clinical behavior within simulated scenarios, qualitative analyses uncovered 3 themes believed important to physician decision-making processes. Overt diagnostic focus may have resulted from the study environment in addition to organizational factors, policies, and training. Discharge planning, which was not explicitly studied, was often tailored to SES with emphasis placed on risks for patients of low SES. Further research is needed to uncover the nuances of bias, SES, and physician decision making throughout the patient care continuum and within various clinical environments.

Racial/Ethnic and Socioeconomic Disparities in Osteoarthritis Management

This article reviews the literature on racial and socioeconomic disparities in the management of osteoarthritis. Treatments investigated include arthritis education, dietary weight management, exercise/physical therapy, pharmacologic therapy with nonsteroidal antiinflammatory drugs and opioids, intra-articular steroid injections, and total joint replacement. The amount of evidence for each treatment modality varied, with the most evidence available for racial and socioeconomic disparities in total joint arthroplasty. Black patients, Hispanic patients, and patients with low socioeconomic status (SES) are less likely to undergo total joint replacement than white patients or patients with high SES, and generally have worse functional outcomes and more complications.

Racial Implicit Associations in Psychiatric Diagnosis, Treatment, and Compliance Expectations

OBJECTIVE

Racial and ethnic disparities are well documented in psychiatry, yet suboptimal understanding of underlying mechanisms of these disparities undermines diversity, inclusion, and education efforts. Prior research suggests that implicit associations can affect human behavior, which may ultimately influence healthcare disparities. This study investigated whether racial implicit associations exist among medical students and psychiatric physicians and whether race/ethnicity, training level, age, and gender predicted racial implicit associations.

METHODS

Participants completed online demographic questions and 3 race Implicit Association Tests (IATs) related to psychiatric diagnosis (psychosis vs. mood disorders), patient compliance (compliance vs. non-compliance), and psychiatric medications (antipsychotics vs. antidepressants). Linear and logistic regression models were used to identify demographic predictors of racial implicit associations.

RESULTS

The authors analyzed data from 294 medical students and psychiatric physicians. Participants were more likely to pair faces of Black individuals with words related to psychotic disorders (as opposed to mood disorders), non-compliance (as opposed to compliance), and antipsychotic medications (as opposed to antidepressant medications). Among participants, self-reported White race and higher level of training were the strongest predictors of associating faces of Black individuals with psychotic disorders, even after adjusting for participant's age.

CONCLUSIONS

Racial implicit associations were measurable among medical students and psychiatric physicians. Future research should examine (1) the relationship between implicit associations and clinician behavior and (2) the ability of interventions to reduce racial implicit associations in mental healthcare.

Disparities in Health Care for Black Patients in Physical Medicine and Rehabilitation in the United States: A Narrative Review

Racial health disparities continue to disproportionately affect Black persons in the United States. Black individuals also have increased risk of worse outcomes associated with social determinants of health including socioeconomic factors such as income, education, and employment. This narrative review included studies originally spanning a period of approximately one decade (December 2009-December 2019) from online databases and with subsequent updates though June 2020. The findings to date suggest pervasive inequities across common conditions and injuries in physical medicine and rehabilitation for this group compared to other racial/ethnic groups. We found health disparities across several domains for Black persons with stroke, traumatic brain injury, spinal cord injury, hip/knee osteoarthritis, and fractures, as well as cardiovascular and pulmonary disease. Although more research is needed, some contributing factors include low access to rehabilitation care, fewer referrals, lower utilization rates, perceived bias, and more self-reliance, even after adjusting for hospital characteristics, age, disease severity, and relevant socioeconomic variables. Some studies found that Black individuals were less likely to receive care that was concordant with clinical guidelines per the reported literature. Our review highlights many gaps in the literature on racial disparities that are particularly notable in cardiac, pulmonary, and critical care rehabilitation. Clinicians, researchers, and policy makers should therefore consider race and ethnicity as important factors as we strive to optimize rehabilitation care for an increasingly diverse U.S. population.

Addressing Racial Biases in Medicine: A Review of the Literature, Critique, and Recommendations

This article reviews the literature on racism in medicine in the United States and reflects on the persistent barriers to diminishing racial biases in the U.S. health care system. Espoused strategies for decreasing racial disparities and reducing racial biases among physicians are critiqued, and recommendations are offered. Those recommendations include increasing the number of minority students in medical school, using Xavier University in New Orleans, Louisiana, as the model for medical school preparation; revamping the teaching of cultural competence; ensuring the quality of non-clinical staff; and reducing the risk of burnout among medical providers.

Racial Bias and Its Impact on Children and Adolescents

Racial bias is pervasive throughout society and can impact children and adolescents in the health care, education, and criminal justice systems. This article provides a state-of-the-science review of implicit bias in health care. It also reviews the evidence of how bias impacts children in other aspects of society, explores bias as it relates to the broader context of structural racism in America, and summarizes the impact of bias and discrimination on youth academic, behavioral, and health outcomes. Evidence-based strategies are provided to help pediatricians identify and confront their own personal biases.

A Cross-Sectional Study to Investigate the Effects of Perceived Discrimination in the Health Care Setting on Pain and Depressive Symptoms in Wheelchair Users With Spinal Cord Injury

OBJECTIVES

In a sample of wheelchair users with spinal cord injury (SCI), the objectives were to investigate which participant characteristics are associated with greater perceived discrimination in the health care setting, and how such discrimination relates to health outcomes of pain and depressive symptoms.

DESIGN

Survey, cross-sectional.

SETTING

Spinal Cord Injury Model Systems (SCIMS) Center.

PARTICIPANTS

Full-time wheelchair users with SCI from 9 SCIMS centers (N=410), with data collected between 2011 and 2016.

INTERVENTIONS

N/A.

MAIN OUTCOMES

A 7-item questionnaire inquiring about perceived discrimination by hospital staff, self-reported pain severity over the past month using a 0-10 Numeric Rating Scale, and depressive symptoms using the 2-question Patient Health Questionnaire screener.

RESULTS

Participants who were black or from the lowest income group were more likely to report experiencing more discrimination than those who were white or from the highest income group, respectively (incidence rate ratio=2.2-2.6, P<.01). Those who reported more perceived discrimination had greater risk of severe pain compared to no pain (relative risk [RR]=1.11; 95% confidence interval [95% CI], 1.01-1.23; P<.05), mild depressive symptoms (RR=1.09; 95% CI, 1.02-1.17; P<.05), and severe depressive symptoms (RR=1.12; 95% CI, 1.04-1.21; P<.05) compared to no symptoms.

CONCLUSIONS

Wheelchair users with SCI who were from more disadvantaged groups (black, lower income levels) reported experiencing more discrimination in their health care setting. Furthermore, those who reported more discrimination were more likely to report worse mental and physical health outcomes. Attempts to reduce discrimination in health care settings may lead to better outcomes for people with SCI. These observations were correlational and not causal; a prospective analysis is necessary to prove causation. Future investigations should further explore the effect of discrimination on the many facets of living with an SCI.

A Qualitative Study of New York Medical Student Views on Implicit Bias Instruction: Implications for Curriculum Development

BACKGROUND

For at least the past two decades, medical educators have worked to improve patient communication and health care delivery to diverse patient populations; despite efforts, patients continue to report prejudice and bias during their clinical encounters. Targeted instruction in implicit bias recognition and management may promote the delivery of equitable care, but students at times resist this instruction. Little guidance exists to overcome this resistance and to engage students in implicit bias instruction; instruction over time could lead to eventual skill development that is necessary to mitigate the influence of implicit bias on clinical practice behaviors.

OBJECTIVE

To explore student perceptions of challenges and opportunities when participating in implicit bias instruction.

APPROACH

We conducted a qualitative study that involved 11 focus groups with medical students across each of the four class years to explore their perceptions of challenges and opportunities related to participating in such instruction. We analyzed transcripts for themes.

KEY RESULTS

Our analysis suggests a range of attitudes toward implicit bias instruction and identifies contextual factors that may influence these attitudes. The themes were (1) resistance; (2) shame; (3) the negative role of the hidden curriculum; and (4) structural barriers to student engagement. Students expressed resistance to implicit bias instruction; some of these attitudes are fueled from concerns of anticipated shame within the learning environment. Participants also indicated that student engagement in implicit bias instruction was influenced by the hidden curriculum and structural barriers.

CONCLUSIONS

These insights can inform future curriculum development efforts. Considerations related to instructional design and programmatic decision-making are highlighted. These considerations for implicit bias instruction may provide useful frameworks for educators looking for opportunities to minimize student resistance and maximize engagement in multi-session instruction in implicit bias recognition and management.

Nonverbal synchrony as a behavioural marker of patient and physician race-related attitudes and a predictor of outcomes in oncology interactions: protocol for a secondary analysis of video-recorded cancer treatment discussions

INTRODUCTION

Racial disparities in cancer treatment contribute to racial disparities in mortality rates. The quality of patient-physician communication during clinical interactions with black patients and non-black physicians (racially discordant) is poorer than communication quality with white patients (racially concordant). Patient and physician race-related attitudes affect the quality of this communication. These attitudes are likely expressed through subtle non-verbal behaviours, but prior research has not examined these behaviours. Nonverbal synchrony, the coordination of physical movement, reflects the preinteraction attitudes of participants in interactions and predicts their postinteraction perceptions of and affect towards one another. In this study, peer reviewed and funded by the National Institute of Minority Health and Health Disparities (R21MD011766), we will investigate non-verbal synchrony in racially concordant and discordant interactions to better understand racial disparities in clinical communication.

METHODS AND ANALYSIS

This secondary analysis includes racially concordant (n=163) and racially discordant (n=68) video-recorded oncology interactions, patient and oncologist self-reported race-related attitudes, perceptions of the interaction and observer ratings of physician patient-centred communication and patient and physician affect and rapport. In aim 1, we will assess and compare non-verbal synchrony between physicians and patients in racially concordant and discordant interactions. In aim 2, we will determine the influence of non-verbal synchrony on patient and physician affect and communication. In aim 3, we will examine possible causes (ie, race-related attitudes) and consequences (ie, negative perceptions) of non-verbal synchrony in racially discordant interactions. In aim 4, we will develop and test a mediational model linking physician and patient race-related attitudes to non-verbal synchrony and, in turn, interaction outcomes.

ETHICS AND DISSEMINATION

The parent and current studies were approved by the Wayne State University Institutional Review Board. Since only archival data will be used, ethical or safety risks are low. We will disseminate our findings to relevant conferences and journals.

How to Make or Break Implicit Bias Instruction: Implications for Curriculum Development

PURPOSE

To analyze faculty experiences regarding facilitating discussions as part of the institution's curriculum on racial and ethnic implicit bias recognition and management.

METHOD

Between July 2014 and September 2016, the authors conducted 21 in-depth interviews with faculty who had experience teaching in implicit bias instruction or were interested in facilitating discussions related to implicit bias and the Implicit Association Test. Grounded theory methodology was used to analyze interview transcripts.

RESULTS

Participants identified challenges that affect their ability to facilitate instruction in implicit bias. Faculty described the influence of their own background and identities as well as the influence of institutional values on their ability to facilitate implicit bias discussions. They noted the impact of resistant learners and faculty during discussions and made suggestions for institutional measures including the need for implementation of formalized longitudinal implicit bias curricula and faculty development.

CONCLUSIONS

Faculty facilitating sessions on implicit bias must attend faculty development sessions to be equipped to deal with some of the challenges they may face. Buy-in from institutional leadership is essential for successful implementation of implicit bias teaching, and medical educators need to consider formalized longitudinal curricula addressing the recognition and management of implicit biases.

Patient perspectives on racial and ethnic implicit bias in clinical encounters: Implications for curriculum development

OBJECTIVE

Patients describe feelings of bias and prejudice in clinical encounters; however, their perspectives on restoring the encounter once bias is perceived are not known. Implicit bias has emerged as a target for curricular interventions. In order to inform the design of novel patient-centered curricular interventions, this study explores patients' perceptions of bias, and suggestions for restoring relationships if bias is perceived.

METHODS

The authors conducted bilingual focus groups with purposive sampling of self-identified Black and Latino community members in the US. Data were analyzed using grounded theory.

RESULTS

Ten focus groups (in English (6) and Spanish (4)) with N = 74 participants occurred. Data analysis revealed multiple influences patients' perception of bias in their physician encounters. The theory emerging from the analysis suggests if bias is perceived, the outcome of the encounter can still be positive. A positive or negative outcome depends on whether the physician acknowledges this perceived bias or not, and his or her subsequent actions.

CONCLUSIONS

Participant lived experience and physician behaviors influence perceptions of bias, however clinical relationships can be restored following perceived bias.

PRACTICE IMPLICATIONS

Providers might benefit from skill development in the recognition and acknowledgement of perceived bias in order to restore patient-provider relationships.

Implicit Bias in Pediatric Academic Medicine

OBJECTIVE

Despite known benefits of diversity, certain racial/ethnic groups remain underrepresented in academic pediatrics. Little research exists regarding unconscious racial attitudes among pediatric faculty responsible for decisions on workforce recruitment and retention in academia. This study sought to describe levels of unconscious racial bias and perceived barriers to minority recruitment and retention among academic pediatric faculty leaders.

METHODS

Authors measured unconscious racial bias in a sample of pediatric faculty attending diversity workshops conducted at local and national meetings in 2015. A paper version of the validated Implicit Association Test (IAT) measured unconscious racial bias. Subjects also reported perceptions about minority recruitment and retention.

RESULTS

Of 68 eligible subjects approached, 58 (85%) consented and completed the survey with IAT. Of participants, 83% had leadership roles and 93% were involved in recruitment. Participants had slight pro-white/anti-black bias on the IAT (M = 0.28, SD = 0.49). There were similar IAT scores among participants in leadership roles (M = 0.33, SD = 0.47) and involved in recruitment (M = 0.28, SD = 0.43). Results did not differ when comparing participants in local workshops to the national workshop (n = 36, M = 0.29, SD = 0.40 and n = 22, M = 0.27, SD = 0.49 respectively; p = 0.88). Perceived barriers to minority recruitment and retention included lack of minority mentors, poor recruitment efforts, and lack of qualified candidates.

CONCLUSIONS

Unconscious pro-white/anti-black racial bias was identified in this sample of academic pediatric faculty and leaders. Further research is needed to examine how unconscious bias impacts decisions in academic pediatric workforce recruitment. Addressing unconscious bias and perceived barriers to minority recruitment and retention represent opportunities to improve diversity efforts.

Physician Racial Bias and Word Use during Racially Discordant Medical Interactions

Physician racial bias can negatively affect Black patients' reactions to racially discordant medical interactions, suggesting that racial bias is manifested in physicians' communication with their Black patients. However, little is known about how physician racial bias actually influences their communication during these interactions. This study investigated how non-Black physicians' racial bias is related to their word use during medical interactions with Black patients. One hundred and seventeen video-recorded racially discordant medical interactions from a larger study were transcribed and analyzed using Linguistic Inquiry and Word Count (LIWC) software. Physicians with higher levels of implicit racial bias used first-person plural pronouns and anxiety-related words more frequently than physicians with lower levels of implicit bias. There was also a trend for physicians with higher levels of explicit racial bias to use first-person singular pronouns more frequently than physicians with lower levels of explicit bias. These findings suggest that non-Black physicians with higher levels of implicit racial bias may tend to use more words that reflect social dominance (i.e., first-person plural pronouns) and anxiety when interacting with Black patients.

Comparison of Physician Implicit Racial Bias Toward Adults Versus Children

BACKGROUND AND OBJECTIVES

The general population and most physicians have implicit racial bias against black adults. Pediatricians also have implicit bias against black adults, albeit less than other specialties. There is no published research on the implicit racial attitudes of pediatricians or other physicians toward children. Our objectives were to compare implicit racial bias toward adults versus children among resident physicians working in a pediatric emergency department, and to assess whether bias varied by specialty (pediatrics, emergency medicine, or other), gender, race, age, and year of training.

METHODS

We measured implicit racial bias of residents before a pediatric emergency department shift using the Adult and Child Race Implicit Association Tests (IATs). Generalized linear models compared Adult and Child IAT scores and determined the association of participant demographics with Adult and Child IAT scores.

RESULTS

Among 91 residents, we found moderate pro-white/anti-black bias on both the Adult (mean = 0.49, standard deviation = 0.34) and Child Race IAT (mean = 0.55, standard deviation = 0.37). There was no significant difference between Adult and Child Race IAT scores (difference = 0.06, P = .15). Implicit bias was not associated with resident demographic characteristics, including specialty.

CONCLUSIONS

This is the first study demonstrating that resident physicians have implicit racial bias against black children, similar to levels of bias against black adults. Bias in our study did not vary by resident demographic characteristics, including specialty, suggesting that pediatric residents are as susceptible as other physicians to implicit bias. Future studies are needed to explore how physicians' implicit attitudes toward parents and children may impact inequities in pediatric health care.

Examining the Presence, Consequences, and Reduction of Implicit Bias in Health Care: A Narrative Review

Recent evidence suggests that one possible cause of disparities in health outcomes for stigmatized groups is the implicit biases held by health care providers. In response, several health care organizations have called for, and developed, new training in implicit bias for their providers. This review examines current evidence on the role that provider implicit bias may play in health disparities, and whether training in implicit bias can effectively reduce the biases that providers exhibit. Directions for future research on the presence and consequences of provider implicit bias, and best practices for training to reduce such bias, will be discussed.

The Effects of Oncologist Implicit Racial Bias in Racially Discordant Oncology Interactions

PURPOSE

Health providers' implicit racial bias negatively affects communication and patient reactions to many medical interactions. However, its effects on racially discordant oncology interactions are largely unknown. Thus, we examined whether oncologist implicit racial bias has similar effects in oncology interactions. We further investigated whether oncologist implicit bias negatively affects patients' perceptions of recommended treatments (i.e., degree of confidence, expected difficulty). We predicted oncologist implicit bias would negatively affect communication, patient reactions to interactions, and, indirectly, patient perceptions of recommended treatments.

METHODS

Participants were 18 non-black medical oncologists and 112 black patients. Oncologists completed an implicit racial bias measure several weeks before video-recorded treatment discussions with new patients. Observers rated oncologist communication and recorded interaction length of time and amount of time oncologists and patients spoke. Following interactions, patients answered questions about oncologists' patient-centeredness and difficulty remembering contents of the interaction, distress, trust, and treatment perceptions.

RESULTS

As predicted, oncologists higher in implicit racial bias had shorter interactions, and patients and observers rated these oncologists' communication as less patient-centered and supportive. Higher implicit bias also was associated with more patient difficulty remembering contents of the interaction. In addition, oncologist implicit bias indirectly predicted less patient confidence in recommended treatments, and greater perceived difficulty completing them, through its impact on oncologists' communication (as rated by both patients and observers).

CONCLUSION

Oncologist implicit racial bias is negatively associated with oncologist communication, patients' reactions to racially discordant oncology interactions, and patient perceptions of recommended treatments. These perceptions could subsequently directly affect patient-treatment decisions. Thus, implicit racial bias is a likely source of racial treatment disparities and must be addressed in oncology training and practice.

Functional outcomes during inpatient rehabilitation for American Indian and Alaska Native children with traumatic brain injury

PURPOSE

American Indian/Alaska Native (AI/AN) people have the highest traumatic brain injury (TBI)-related mortality in the United States, but little is known about AI/AN children who survive traumatic brain injury (TBI). This study compares function and factors associated with discharge function between AI/AN and White children with TBI during inpatient rehabilitation.

METHODS

Retrospective national cohort study of 114 AI/AN and 7,267 White children aged 6 months-18 years who received inpatient TBI rehabilitation between 2002-2012 at facilities utilizing the Uniform Data System for Medical Rehabilitation\scriptsize®. The outcome measure was developmental functional quotients (DFQ is the FIM\scriptsize® or WeeFIM\scriptsize® score divided by age norms x 100) at discharge.

RESULTS

AI/AN race was not associated with motor (regression coefficient (β) 0.18, 95% confidence interval (CI) -2.39, 2.76) or cognitive (β -1.54, 95% CI -3.75, 0.67) function. Among a subgroup with loss of consciousness > 24 hours (AI/AN n= 13, White n= 643), AI/AN race was associated with lower motor DFQ (β -12.83, 95% CI -25.39, -0.34).

CONCLUSIONS

Overall, AI/AN race was not associated with inpatient rehabilitation function for children with TBI, but providers should not assume AI/ANs with more severe injuries have equitable outcomes.

The Impact of Cognitive Stressors in the Emergency Department on Physician Implicit Racial Bias

OBJECTIVES

The emergency department (ED) is characterized by stressors (e.g., fatigue, stress, time pressure, and complex decision-making) that can pose challenges to delivering high-quality, equitable care. Although it has been suggested that characteristics of the ED may exacerbate reliance on cognitive heuristics, no research has directly investigated whether stressors in the ED impact physician racial bias, a common heuristic. We seek to determine if physicians have different levels of implicit racial bias post-ED shift versus preshift and to examine associations between demographics and cognitive stressors with bias.

METHODS

This repeated-measures study of resident physicians in a pediatric ED used electronic pre- and postshift assessments of implicit racial bias, demographics, and cognitive stressors. Implicit bias was measured using the Race Implicit Association Test (IAT). Linear regression models compared differences in IAT scores pre- to postshift and determined associations between participant demographics and cognitive stressors with postshift IAT and pre- to postshift difference scores.

RESULTS

Participants (n = 91) displayed moderate prowhite/antiblack bias on preshift (mean ± SD = 0.50 ± 0.34, d = 1.48) and postshift (mean ± SD = 0.55 ± 0.39, d = 1.40) IAT scores. Overall, IAT scores did not differ preshift to postshift (mean increase = 0.05, 95% CI = -0.02 to 0.14, d = 0.13). Subanalyses revealed increased pre- to postshift bias among participants working when the ED was more overcrowded (mean increase = 0.09, 95% CI = 0.01 to 0.17, d = 0.24) and among those caring for >10 patients (mean increase = 0.17, 95% CI = 0.05 to 0.27, d = 0.47). Residents' demographics (including specialty), fatigue, busyness, stressfulness, and number of shifts were not associated with postshift IAT or difference scores. In multivariable models, ED overcrowding was associated with greater postshift bias (coefficient = 0.11 per 1 unit of NEDOCS score, SE = 0.05, 95% CI = 0.00 to 0.21).

CONCLUSIONS

While resident implicit bias remained stable overall preshift to postshift, cognitive stressors (overcrowding and patient load) were associated with increased implicit bias. Physicians in the ED should be aware of how cognitive stressors may exacerbate implicit racial bias.

Differences in Physicians' Verbal and Nonverbal Communication With Black and White Patients at the End of Life

CONTEXT

Black patients are more likely than white patients to die in the intensive care unit with life-sustaining treatments. Differences in patient- and/or surrogate-provider communication may contribute to this phenomenon.

OBJECTIVES

To test whether hospital-based physicians use different verbal and/or nonverbal communication with black and white simulated patients and their surrogates.

METHODS

We conducted a randomized factorial trial of the relationship between patient race and physician communication using high-fidelity simulation. Using a combination of probabilistic and convenience sampling, we recruited 33 hospital-based physicians in western Pennsylvania who completed two encounters with prognostically similar, critically and terminally ill black and white elders with identical treatment preferences. We then conducted detailed content analysis of audio and video recordings of the encounters, coding verbal emotion-handling and shared decision-making behaviors, and nonverbal behaviors (time interacting with the patient and/or surrogate, with open vs. closed posture, and touching the patient and physical proximity). We used a paired t-test to compare each subjects' summed verbal and nonverbal communication scores with the black patient compared to the white patient.

RESULTS

Subject physicians' verbal communication scores did not differ by patient race (black vs. white: 8.4 vs. 8.4, P-value = 0.958). However, their nonverbal communication scores were significantly lower with the black patient than with the white patient (black vs. white: 2.7 vs. 2.9, P-value 0.014).

CONCLUSION

In this small regional sample, hospital-based physicians have similar verbal communication behaviors when discussing end-of-life care for otherwise similar black and white patients but exhibit significantly fewer positive, rapport-building nonverbal cues with black patients.

Implicit Racial/Ethnic Bias Among Health Care Professionals and Its Influence on Health Care Outcomes: A Systematic Review

BACKGROUND

In the United States, people of color face disparities in access to health care, the quality of care received, and health outcomes. The attitudes and behaviors of health care providers have been identified as one of many factors that contribute to health disparities. Implicit attitudes are thoughts and feelings that often exist outside of conscious awareness, and thus are difficult to consciously acknowledge and control. These attitudes are often automatically activated and can influence human behavior without conscious volition.

OBJECTIVES

We investigated the extent to which implicit racial/ethnic bias exists among health care professionals and examined the relationships between health care professionals' implicit attitudes about racial/ethnic groups and health care outcomes.

SEARCH METHODS

To identify relevant studies, we searched 10 computerized bibliographic databases and used a reference harvesting technique.

SELECTION CRITERIA

We assessed eligibility using double independent screening based on a priori inclusion criteria. We included studies if they sampled existing health care providers or those in training to become health care providers, measured and reported results on implicit racial/ethnic bias, and were written in English.

DATA COLLECTION AND ANALYSIS

We included a total of 15 studies for review and then subjected them to double independent data extraction. Information extracted included the citation, purpose of the study, use of theory, study design, study site and location, sampling strategy, response rate, sample size and characteristics, measurement of relevant variables, analyses performed, and results and findings. We summarized study design characteristics, and categorized and then synthesized substantive findings.

MAIN RESULTS

Almost all studies used cross-sectional designs, convenience sampling, US participants, and the Implicit Association Test to assess implicit bias. Low to moderate levels of implicit racial/ethnic bias were found among health care professionals in all but 1 study. These implicit bias scores are similar to those in the general population. Levels of implicit bias against Black, Hispanic/Latino/Latina, and dark-skinned people were relatively similar across these groups. Although some associations between implicit bias and health care outcomes were nonsignificant, results also showed that implicit bias was significantly related to patient-provider interactions, treatment decisions, treatment adherence, and patient health outcomes. Implicit attitudes were more often significantly related to patient-provider interactions and health outcomes than treatment processes.

CONCLUSIONS

Most health care providers appear to have implicit bias in terms of positive attitudes toward Whites and negative attitudes toward people of color. Future studies need to employ more rigorous methods to examine the relationships between implicit bias and health care outcomes. Interventions targeting implicit attitudes among health care professionals are needed because implicit bias may contribute to health disparities for people of color.

Reducing Racial Health Care Disparities: A Social Psychological Analysis

Large health disparities persist between Black and White Americans. The social psychology of intergroup relations suggests some solutions to health care disparities due to racial bias. Three paths can lead from racial bias to poorer health among Black Americans. First is the already well-documented physical and psychological toll of being a target of persistent discrimination. Second, implicit bias can affect physicians' perceptions and decisions, creating racial disparities in medical treatments, although evidence is mixed. The third path describes a less direct route: Physicians' implicit racial bias negatively affects communication and the patient-provider relationship, resulting in racial disparities in the outcomes of medical interactions. Strong evidence shows that physician implicit bias negatively affects Black patients' reactions to medical interactions, and there is good circumstantial evidence that these reactions affect health outcomes of the interactions. Solutions focused on the physician, the patient, and the health care delivery system; all agree that trying to ignore patients' race or to change physicians' implicit racial attitudes will not be effective and may actually be counterproductive. Instead, solutions can minimize the impact of racial bias on medical decisions and on patient-provider relationships.